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Date run 4!912015 4:09:06PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 45025 <br /> Pagel <br /> Run by Facility Information as of 419/2015 <br /> Record Selection Criteria Facility ID FAG022852 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner : 1 SSN f Fed Tax ID <br /> Owner ID OW0020810 New Owner ID <br /> Owner Name Verizon Wireless <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 866-694-2415 <br /> Mailing Address 255 Parkshore Drive <br /> Folsom, CA 95630 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID I CERS ID FA0022852 10612078 <br /> Facility Name Verizon Wireless Pillsbury <br /> Location 1759 Moffat Blvd <br /> Manteca, CA 95336 <br /> Phone 866-694-2415 x <br /> Mailing Address 255 Parkshore Drive <br /> Folsom, CA 95630 - <br /> Care of Verizon Wireless <br /> Location Code Aft Phone <br /> BOS District Fax <br /> APN 228-050-17 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0041922 New Account ID: <br /> Mail Invoices to Account Maid Invoices to: Owner I Facility ! Account <br /> Account Name Environmental Compliance (Circle One) <br /> Account Balance as of 41912015: $$0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> ProgramFElemert and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PR0539977 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andior Standards and State angor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date ! / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date I f <br /> Water System to be TRANSFERED: Amount Paid Date I 1 <br /> Payment Type Check Number Receive by <br /> REHS: Z Date 9 ll Account out: Date r � /-I <br /> COMMENTS: <br /> V1 PIC CHIC-S , <br />